AccountId: 011433970860
ContactId: f5bffd17-ac4e-48d4-9e8a-8952178d81ab
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 633400 ms
Total Talk Time (AGENT): 204039 ms
Total Talk Time (CUSTOMER): 107060 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/f5bffd17-ac4e-48d4-9e8a-8952178d81ab_20250501T14:03_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello, I'd like to get some eligibility for a patient.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the eligibility. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] It's right and the phone number is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the member's policy number whenever you're ready.
[CUSTOMER][NEUTRAL] Policy number is.
[CUSTOMER][NEUTRAL] 1065324
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment, and I am showing the policy is active. It's been effective since January, I'm sorry, [PII].
[CUSTOMER][NEUTRAL] Is there any network for the plan?
[AGENT][NEUTRAL] Um, hold on one moment, let me see what type of policy they have.
[AGENT][NEUTRAL] And for this dental policy, there's no network.
[AGENT][NEUTRAL] We are on a Carrington fee schedule though.
[CUSTOMER][NEUTRAL] Carrington fee schedule?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Would you like, um, did you need a copy of the fax back with the benefits and everything on it?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so on the fax back you'll see the calendar year maximum deductible, all the percentage percentages, frequencies, um, all the ways to file a claim and then there's a list of covered codes. If the code you're looking for is not on this list, then it wouldn't be covered by the policy. And what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And should I put attention [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, and that was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] All right, so I'm sending this over to you now. And was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Would [PII] be eligible for 11:10?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] The box to send the fax just popped up and then I'll check that for you. All right, so I just sent that to you and then let me check the history.
[AGENT][NEUTRAL] And you, which code did you say 1110?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Alright, so the last day of service was [PII], May, June, July, August, September, October, [PII].
[AGENT][NEUTRAL] So yes, they're eligible. It's once every 6 months, so November, they would have been eligible.
[CUSTOMER][NEUTRAL] Is there any waiting period or missing two costs?
[AGENT][NEGATIVE] So there is a missing tooth cloth.
[AGENT][POSITIVE] And there is a, uh, well, there was a waiting period, um, but it was only 12 months and this policy has surpassed that.
[CUSTOMER][NEUTRAL] And for 1208, is there a age limit?
[AGENT][NEUTRAL] Um, 1208 is not a covered code on this policy.
[CUSTOMER][NEUTRAL] 4381.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] You said 4381?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, yes, that's covered under major.
[AGENT][NEUTRAL] At 40%?
[CUSTOMER][NEUTRAL] Is there any guidelines?
[AGENT][NEUTRAL] For 4381, no.
[CUSTOMER][NEUTRAL] Would it be allowed same day as SRP or periodontal maintenance?
[AGENT][NEUTRAL] Um, it can be, there's no specification for it. There's no limitations.
[CUSTOMER][NEUTRAL] And the code 9944?
[AGENT][NEUTRAL] 9944 is not a cover code on this policy.
[CUSTOMER][NEUTRAL] SRP, um, is there any healing period after SRP?
[AGENT][NEUTRAL] Um, our policy doesn't specify healing period.
[CUSTOMER][NEUTRAL] And what's the timely filing for claim?
[AGENT][NEUTRAL] Um, there's no timely filing limit. You can file at any time as long as the policy was active on the data service.
[CUSTOMER][NEUTRAL] So if a provider is not in network with Carrington still use the Carrington fee schedule?
[AGENT][NEUTRAL] Yes, because this policy doesn't have a network.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there any downgrading?
[AGENT][NEUTRAL] Um, no downgrade.
[CUSTOMER][NEUTRAL] Does the plan pay on prep or seat date?
[AGENT][NEUTRAL] Um, it could be either or.
[CUSTOMER][NEUTRAL] Is there any history on file for this year?
[AGENT][NEUTRAL] For this year, let me see.
[AGENT][NEUTRAL] No, not for [PII] yet.
[CUSTOMER][NEUTRAL] And the patient [PII], they will be the policy holder.
[AGENT][NEUTRAL] Yes, um, that is the policyholder, it's an individual policy.
[CUSTOMER][NEUTRAL] Any history of SRP?
[AGENT][NEUTRAL] Um, is there, do you have a code for that?
[CUSTOMER][NEUTRAL] 4341.
[AGENT][NEUTRAL] Um, 4341.
[AGENT][NEUTRAL] Excuse me, it's covered under periodontic, which is major at 40%, and let me see, maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] Does 4910 and 1110 share frequency?
[AGENT][NEUTRAL] Um, yes, it's once every 6 months.
[CUSTOMER][NEUTRAL] Is there any ortho benefits?
[AGENT][NEUTRAL] Um, no. Orthodontic treatment is not covered on this policy.
[CUSTOMER][NEUTRAL] Any implant coverage?
[AGENT][NEUTRAL] Implant placement, removal, and all related services are not covered on this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And could I have your name again and a reference number?
[AGENT][NEUTRAL] Sure, my name is [PII] First initial to my last name is [PII], and there is no call reference number, but you can use my name and today's date.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And you say you already sent the fax back.
[AGENT][NEUTRAL] Yes, the fax back has been sent to you. If you don't receive it by the end of day today.
[AGENT][POSITIVE] Um, you can definitely give us a call back and we'll be more than happy to resend it for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Alrighty, and was it? Alright, well thank you so much for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] That'll be all.
[CUSTOMER][POSITIVE] You too thank you.
[AGENT][POSITIVE] Thank you, you're welcome. Bye bye.